Burden of copy number variation in common variable immunodeficiency.

Common variable immunodeficiency (CVID) has been associated recently with a dramatic increase in total copy number variation burden, the cause of which is unclear. In order to explore further the origin and clinical relevance of this finding, we quantified the total genomic copy number variation (CNV) burden in affected patients and evaluated clinical details in relationship to total CNV burden. No correlation was found between total CNV burden and either patient age or time elapsed since symptom onset, and higher total burden did not correlate with incidence of malignancy or other subphenotypes. These findings suggest that the increased CNV burden is static and intrinsic to CVID as a disease.

Pregabalin Improves Fibromyalgia-related Sleep Disturbance.

OBJECTIVE: To investigate the effect of pregabalin on wake and sleep bout parameters. MATERIALS AND METHODS: A post hoc analysis of polysomnography data from a randomized, placebo-controlled, crossover study investigating the effect of pregabalin (150 to 450 mg/d) and placebo on sleep in fibromyalgia (FM). Eligible patients had FM and sleep-maintenance problems, including wake after sleep onset ≥45 minutes and total sleep time (TST) 3.0 to 6.5 hours, but no other sleep/circadian rhythm disorders. Polysomnography was performed for 2 consecutive nights (screening, post-treatment). Wake and sleep bout duration and frequency were derived; a "bout"=consecutive 30-s epochs of sleep or wake. RESULTS: Of 119 patients randomized (103 [87%] female), data were available for 103 treated with pregabalin and 106 with placebo. Pregabalin versus placebo treatment decreased mean±SD number of wake/sleep bouts (33.24±1.33 vs. 36.85±1.32; difference: -3.61 [95% confidence interval, -6.03, -1.18]; P=0.0039) and increased sleep bout duration (15.25±0.63 vs. 11.58±0.62 min; +3.67 min [2.22, 5.12 min]; P<0.0001). Pregabalin decreased mean duration of wake bouts versus placebo (3.41±0.55 vs. 3.94±0.55 min; -0.53 min [-1.06, -0.002 min]; P=0.0493). An exploratory correlation analysis of treatment effects found stage 1 sleep was negatively correlated with wake and sleep bout duration and positively with wake/sleep bout number; slow wave sleep (%total sleep time) was positively correlated with wake and sleep bout duration and negatively with wake/sleep bout number. CONCLUSIONS: Pregabalin improved sleep parameters characteristic of disturbed sleep in FM, by preventing awakenings and increasing sleep bout duration. These effects are reflected in, and correlated with, a decrease in "light sleep" (stage 1) and an increase in "deep sleep" (slow wave sleep).

Characteristics of Disturbed Sleep in Patients With Fibromyalgia Compared With Insomnia or With Pain-Free Volunteers.

OBJECTIVE: To investigate the differential nature of disturbed sleep in patients with fibromyalgia (FM) reporting sleep difficulties versus patients with primary insomnia (PI) and patients who do not report disturbed sleep (pain-free controls). MATERIALS AND METHODS: Patients (FM: n=132; PI: n=109; normals: n=52) were recruited for different studies. FM and PI patients were preselected to meet the sleep disturbance criteria. Patients with sleep or circadian disorders were excluded from all groups. Polysomnography was conducted at screening, during 2 consecutive nights. For this post hoc analysis of polysomnographies, length and frequency (duration, number) of wake and sleep bouts were analyzed, together with traditional sleep measures; a "bout"=consecutive 30-second epochs of sleep or wake. Data are mean±SD. RESULTS: FM and PI patients had decreased total sleep time and slow-wave sleep (SWS), and increased latency to persistent sleep (LPS) and wake time after sleep onset (WASO) versus controls (P<0.05 for each). FM versus PI patients had more SWS (48.1±32.4 vs. 27.2±23.6 min; P<0.0001) and shorter LPS (58.2±29.8 vs. 70.7±31.3 min; P=0.0055), but comparable WASO (107.7±32.8 vs. 108.6±31.5 min). Despite comparable WASO, FM patients had shorter (4.64±2.42 vs. 5.87±3.15 min; P=0.0016) but more frequent wake bouts versus PI patients (41.6±16.7 vs. 35.7±12.6; P=0.0075). Sleep bout duration was similar for FM (9.32±0.35 min) and PI patients (10.1±0.37 min); both populations had shorter sleep bout duration versus controls (15.7±0.7 min; P<0.0001 both). CONCLUSIONS: Increased frequency of wake and sleep bouts and decreased wake bout duration, together with decreased LPS and increased SWS, suggests that sleep in FM is characterized by an inability to maintain continuous sleep but a greater sleep drive compared with PI.

Transcriptional regulation by a naturally occurring truncated rat estrogen receptor (ER), truncated ER product-1 (TERP-1).

Truncated estrogen receptor product-1 (TERP-1) is a naturally occurring rat estrogen receptor (ER) variant transcribed from a unique start site and containing a unique 5'-untranslated region fused to exons 5-8 of ERalpha. TERP-1 is detected only in the pituitary, and TERP-1 mRNA levels are highly regulated during the estrous cycle, exceeding those of the full-length ERalpha on proestrus. These data suggest that TERP-1 may play a role in estrogen- regulated feedback in the pituitary. We examined the ability of TERP-1 to modulate gene transcription in transiently transfected ER-negative (Cos-1) and ER-positive pituitary (alphaT3 and GH3) cell lines. In Cos-1 cells transiently cotransfected with TERP-1 and either ERalpha or ERbeta, low levels of TERP-1 (ratios of < 1:1 with ER) enhanced transcription of model promoters containing estrogen response elements by an average of 3- to 4-fold above that seen with ER alone. At higher concentrations of TERP-1 (> 1:1 with ER) transcription was inhibited. TERP-1 also had a biphasic action on transcription in the alphaT3 and GH3 pituitary cell lines, although the stimulatory action was less pronounced. TERP-1 actions were dependent on ligand-activated ER as TERP-1 did not bind estradiol in transfected Cos-1 cells or in vitro, and estrogen antagonists prevented the stimulatory effects of TERP-1. Coimmunoprecipitation studies suggest that TERP-1 does not bind with high affinity to the full-length ERalpha. However, TERP-1 may compete with ER for binding sites of receptor cofactors because steroid receptor coactivator-1 (SRC-1) rescued the inhibitory actions of TERP-1. The ability of TERP-1 to both enhance and inhibit ER-dependent promoter activity suggests that TERP-1 may play a physiological role in estrogen feedback in the rat pituitary.

Ligand-independent activation of pituitary ER: dependence on PKA-stimulated pathways.

In pituitary and other target tissues, estrogen acts through ERs, which are ligand-activated nuclear transcription factors. ERs can also be activated by intracellular signaling pathways in a ligand-independent manner in some cells. Because the pituitary is the target of several cAMP-activating factors, we examined the ability of cAMP to activate ERs in the alphaT3 gonadotrope cell line. Forskolin, 8-bromo-cAMP, and pituitary adenylate cyclase-activating polypeptide all enhanced ER-dependent promoter activity, which was inhibited by antiestrogen or a pituitary-specific inhibitory ER variant. Activation was PKA dependent and was blocked by the PKA inhibitor H89 or cotransfection of the inhibitor PKI. Although cAMP activated MAPK in alphaT3 cells, inhibition of MAPK with the MEK inhibitor PD98059 did not prevent forskolin-induced ER activation. Similarly, epidermal growth factor did not stimulate ER activity, although it increased MAPK activation. Forskolin-induced activation of ER was enhanced by cotransfection of steroid receptor coactivator-1 and was inhibited by the repressor of ER action, suggesting that cAMP does not alter the normal interactions between ER and cofactors. In contrast to results with estrogen, cAMP treatment did not decrease ER protein levels. These results demonstrate that in the pituitary, cAMP activates ER in a ligand-independent manner exclusively through PKA.

l-Alpha-acetylmethadol (LAAM): prognostic considerations.

The authors studied the responses of 28 adult male volunteers who were openly changed from methadone to l-alpha-acetylmethadol (LAAM) maintenance. They found that patients who had been receiving middle-range doses (50-70 mg) of methadone required a significantly lower mean increase in LAAM than patients who had been receiving either high or low methadone doses and that the patients who accepted LAAM differed significantly from those who did not in MMPI 2-point-code ratings and mean social adjustment scale scores. These findings may provide prognostic indicators for response to LAAM, a possible alternative to methadone.

Specific modulation of estrogen receptor mRNA isoforms in rat pituitary throughout the estrous cycle and in response to steroid hormones.

We have identified several estrogen receptor (ER) mRNA isoforms in rat pituitary and characterized their regulation by gonadal steroids. The ER mRNAs correspond to splice variants in which either exon 4, exons 3 and 4, or exons 5 and 6 are deleted. A previously isolated pituitary-specific truncated mRNA, TERP-1, containing a unique 5'-end and exons 5 through 8 of the full-length ER, was also studied. The exon deletion variants were expressed in males and females, in pituitary, uterus, testes, heart, hypothalamus, and liver. An antibody to the ER C-terminus bound to full-length (64 kDa) and smaller (50 55 kDa and 40-45 kDa) ER proteins in uterus and pituitary and a pituitary-specific ER of 20-24 kDa corresponding to TERP-1. Estrogen (E) treatment in vivo stimulated full-length ER 2-3-fold, and TERP-1 7-10-fold, but had no effect on any exon deletion variant. Progesterone treatment, alone or with E, had no consistent effect on any ER mRNA form. TERP-1 mRNA was also dramatically and specifically modulated during the estrous cycle, increasing approximately 500-fold between the morning of diestrous and the afternoon of proestrus. Thus, ER mRNA variants exist in estrogen-responsive tissues; the pituitary contains at least one tissue-specific ER which is regulated by steroids and which may contribute to changes in regulated biological activity.

The effect of L-tryptophan on seasonal affective disorder.

Serotonin has been implicated in the etiology of seasonal affective disorder (SAD). The authors compared the effect of the serotonergic precursor L-tryptophan, placebo, and artificial evening light on 13 SAD sufferers. L-Tryptophan and light were associated with greater improvement than was placebo, but the antidepressant effects of L-tryptophan and light were not significantly different.

Buprenorphine responders: a diagnostic subgroup of heroin addicts?

1. A 26-32 month follow-up of 16 heroin-dependent subjects who entered a pilot trial of treatment with buprenorphine (a mixed agonist/antagonist) suggests that positive response to treatment may identify a subgroup of untreated addicts whose levels of psychosocial functioning are intermediate between those for whom methadone (a pure agonist) or naltrexone (a pure antagonist) would be indicated. 2. Buprenorphine's pharmacologic profile provides a missing link in available modalities for opiate dependence treatment, making it acceptable for many addicts who will not accept methadone maintenance treatment, join a residential therapeutic community, or be successful on naltrexone treatment. 3. Eight of the 16 ss were abstinent from heroin while receiving 0.6-3.9 mg/day buprenorphine and counseling. Responders (mean age 34 yrs) had been heroin dependent for a mean of 9.5 years (range 6-17 yrs), all were self-supporting, 4 lived with a non-addicted spouse, 5 had no prior treatment for addiction and 3 had prior naltrexone treatment, but had discontinued it and relapsed. Non-responders (mean age 30 yrs) had been heroin dependent for a mean of 7.4 yrs (range 2-19 yrs), 7 had no regular employment, all were single and 7 had no prior treatment for addiction. 4. Levels of psychosocial functioning (work, home, leisure) and global assessments of functioning were significantly higher for buprenorphine responders than non-responders (p less than .001 and p less than .01 respectively). 5. A new formulation of buprenorphine needs to be developed for addiction treatment, ideally consisting of 0.5 mg and 2.0 mg sublingual tablets.

Cocaine abuse and its treatment.

Increasing numbers of individuals with a diagnosis of cocaine abuse (DSM-III, 305.6) are seeking medical and psychiatric care. The majority of users inhale the drug in powdered form, as cocaine is rapidly absorbed by mucous membranes. The patterns of use resemble those for the use of alcohol and marijuana: recreational, intensified, circumstantial, and compulsive. When cocaine is taken intravenously or by freebasing, individuals are much more vulnerable to developing a compulsive pattern of use that could lead to an organic delusional syndrome. Cocaine causes systemic effects that are similar to those of amphetamine, but they have a much shorter duration of action. Blood pressure, heart rate, feelings of "pleasantness" and "stimulation" are increased, and hunger is decreased. Acute tolerance may develop over hours of continuous use, but it disappears after a short period of abstinence (overnight). In psychomotor testing, performance that is impaired by fatigue is restored to baseline levels. Users like cocaine because they feel more alert, energetic, sociable, and sensual. However, these positive feelings are commonly followed by anxiety, depression, irritability, fatigue, and craving more cocaine. Chronic intoxication is always associated with adverse psychosocial sequelae. Treatment initially must be directed toward the patient's stopping all use of cocaine, employing strategies such as contingency contracts, urinalysis, family intervention, the assignment of financial control to others, or hospitalization. Several psychopharmacologic agents are helpful as an adjunct to a comprehensive treatment plan. Overdoses of cocaine are treated by diazepam and propranolol. Antidepressant medications, both TCAs and MAOIs, often help relieve the symptoms of depression that emerge when chronic use of cocaine is discontinued. Classical and operant conditioning contribute to craving for the drug and opportunities to extinguish these factors are valuable in preventing relapse. Compulsive users often have an Axis II diagnosis of borderline or narcissistic personality disorder, which require long-term psychodynamic psychotherapy.

Methadone and naltrexone in the treatment of heroin dependence.

Over the past 20 years, methadone maintenance has been shown to be a safe, effective treatment for large numbers of heroin addicts. The majority of patients derive major benefits while in treatment, most measurably in the areas of decreased use of illicit opiates, diminished criminality, increased levels of employment and more stable interpersonal relationships. An advantage of methadone maintenance over other treatments is that it attracts and retains a relatively large segment of the addict population and is reasonably cost-effective. Naltrexone is well suited as a transitional treatment for individuals who have progressed using methadone maintenance. Patients completing a course of methadone maintenance should be encouraged to use naltrexone during the postmethadone period, when symptoms of protracted abstinence often lead them to reinitiate use of heroin. Those with stable family relationships, good jobs, minimal antisocial behavior, and low drug-craving before beginning a course of naltrexone appear to benefit most from the treatment. Rates of retention improve when naltrexone is used within a comprehensive rehabilitation program. Although addicted individuals are often stereotyped, they are, in fact, a heterogeneous group representing a range of psychopathologies and life situations. Thus, within any one facility, a variety of modalities should be available to allow treatment to be tailored to the individual. No single treatment is best for all patients, and, moreover, the preferred modality for any one individual may change over time as a result of progress in treatment or varying life circumstances. Multimodality programs that include methadone and naltrexone enable the maximal number of individuals to benefit from treatment.

Rates of heat-induced DNA purine alterations in synthetic polydeoxyribonucleotides.

Damage to DNA by heat can occur at physiological conditions. The effects of the varying conformational states adopted by double-stranded DNA on the incidences and distributions of thermally induced hydrolytic purine alterations are unknown. The possible role of conformational changes on damage by heat to purines in DNA polymers was therefore investigated. Model compounds used were the synthetic alternating copolymer poly(dG-dC):poly(dG-dC) and the homopolymer poly(dG):poly(dC). Base damages were assayed by high performance liquid chromatography using polymers radioactively labeled in guanine. Conformational states were assayed by circular dichroic spectral changes. Incubation and heating of the polymers in 1 mM Mn2+ caused the spectral shift reported for the left-handed Z-DNA conformation in the alternating copolymer and the change reported for the triple helix in the homopolymer. After incubation at 85 degrees C., incidences of base damages were compared between the polymers. No deamination of guanine to xanthine was observed under any conditions. The presence of manganese reduced depurination in both polymers. Rates of guanine imidazole ring openings to yield 2,6-diamino-4-hydroxy-5-formamidopyrimidine were increased in the presence of the cation and constituted the chief form of purine damage in the homopolymer. Therefore, the distribution of heat-induced DNA alterations within the genome may be determined by DNA conformational states. This observed opening of purine imidazole rings in the presence of manganese ions may have mutagenic consequences and may be involved in carcinogenesis by metals.

Exacerbation of acetazolamide teratogenesis by amiloride and its analogs active against Na+/H+ exchangers and Na+ channels.

Postaxial forelimb ectrodactyly induced by acetazolamide given on Day 9.5 of murine gestation is thought to be mediated by reduced intracellular pH (pHi) within the limb bud. Coadministration of amiloride increases the incidence and severity of acetazolamide-induced forelimb malformations and further reduces limb bud pHi. These findings were hypothesized to be attributable to the action of amiloride as an inhibitor of Na+/H+ exchangers (NHEs), plasma membrane-localized proteins involved in the maintenance of cellular pH homeostasis. Here, we explored this hypothesis further by coadministering with acetazolamide, amiloride, or analogs known to preferentially inhibit NHEs 5-(N-methyl-N-isobutyl)-amiloride, 5-(N, N-hexamethylene)-amiloride, 5-(N, N-dimethyl)-amiloride, and 5-(N-ethyl-N-isopropyl)-amiloride or amiloride-sensitive Na+ channels (benzamil). The coadministration of either amiloride, benzamil, 5-(N, N-dimethyl)-amiloride, 5-(N-ethyl-N-isopropyl)-amiloride, or 5-(N-methyl-N-isobutyl)-amiloride all dose responsively increased the frequency and severity of forelimb malformations compared to acetazolamide alone. None of the analogs given alone induced forelimb ectrodactyly. The data are consistent with the original hypothesis that the exacerbation of acetazolamide teratogenesis is due to NHE inhibition. Surprisingly, benzamil was the most potent potentiator of acetazolamide teratogenesis. This result strongly suggests that amiloride-sensitive Na+ channels are also present within the murine embryo and are likely to play a role in pHi homeostasis.

Cardiovascular alterations in rat fetuses exposed to calcium channel blockers.

Preclinical toxicologic investigation suggested that a new calcium channel blocker, Ro 40-5967, induced cardiovascular alterations in rat fetuses exposed to this agent during organogenesis. The present study was designed to investigate the hypothesis that calcium channel blockers in general induce cardiovascular malformations indicating a pharmacologic class effect. We studied three calcium channel blockers of different structure, nifedipine, diltiazem, and verapamil, along with the new agent. Pregnant rats were administered one of these calcium channel blockers during the period of cardiac morphogenesis and the offspring examined on day 20 of gestation for cardiovascular malformations. A low incidence of cardiovascular malformations was observed after exposure to each of the four calcium channel blockers, but this incidence was statistically significant only for verapamil and nifedipine. All four agents were associated with aortic arch branching variants, although significantly increased only for Ro 40-5967 and verapamil.

Buprenorphine treatment of heroin dependence (detoxification and maintenance) in a private practice setting.

At the conclusion of a 3-year demonstration project in a medical setting in which refusal to accept methadone was an inclusion criterion, 12 subjects were unable to detoxify from buprenorphine and remained adamant in their refusal to enroll in a MMTP. In order to study the feasibility of expanding opportunities for treatment previously unavailable to this under-served population of heroin addicts, these 12 subjects plus an additional 11 subjects (N = 23) were recruited for a 12 months trial of buprenorphine treatment conducted in an office-based setting on a fee-for-service basis. An additional cohort of 40 heroin dependent subjects were entered in a protocol for detoxification only. The findings demonstrate both feasibility and patient acceptance of office based fee-for-service buprenorphine treatment, supporting the need for (1) additional studies of this population and (2) changes in government regulations to reintroduce addiction treatment under physician auspices in private practice settings.

Effect of pregabalin on sleep in patients with fibromyalgia and sleep maintenance disturbance: a randomized, placebo-controlled, 2-way crossover polysomnography study.

OBJECTIVE: To assess the effect of pregabalin on polysomnographic (PSG) measures of sleep and patient-rated sleep, tiredness, and pain in fibromyalgia patients. METHODS: We performed a randomized, double-blind, placebo-controlled, 2-period crossover PSG study. Patients ages ≥18 years with fibromyalgia satisfied subjective and objective sleep disturbance criteria prior to randomization. Eligible patients were randomized (1:1) to pregabalin (300-450 mg/day) or placebo for crossover period 1, and vice versa for period 2. Each crossover period comprised a dose-adjustment and dose-maintenance phase, with a 2-week taper/washout between periods. In-laboratory PSGs were recorded during 2 consecutive nights at screening and at the end of each crossover period. The primary end point was the difference in sleep maintenance defined by PSG-recorded wake after sleep onset (WASO; minutes) between 4 weeks of treatment with pregabalin and with placebo. Other PSG measures; patient-rated sleep, tiredness, and pain; and tolerability were assessed. RESULTS: Of 119 patients randomized (103 women [86.6%], mean age 48.4 years), 102 (85.7%) completed both periods. Patients treated with pregabalin showed a reduction in PSG-determined WASO versus treatment with placebo (week 4 difference: -19.2 minutes [95% confidence interval (95% CI) -26.7, -11.6]; P < 0.0001). Pain score improved (decreased) with pregabalin versus placebo treatment at all 4 weeks (week 4 difference: -0.52 [95% CI -0.90, -0.14]; P = 0.0084). Modest (ρ = <0.3) but significant correlations were found between PSG sleep assessments and ratings of pain and sleep quality. Frequently reported all-causality adverse events (pregabalin versus placebo) were: dizziness (30.4% versus 9.9%), somnolence (20.5% versus 4.5%), and headache (8.9% versus 8.1%). CONCLUSION: Patients with fibromyalgia treated with pregabalin had statistically significant and meaningful improvements in sleep, as assessed by PSG. Patients with fibromyalgia also reported decreased daily pain. Pregabalin was well tolerated.

Memantine treatment of cognitive symptoms in mild to moderate Alzheimer disease: secondary analyses from a placebo-controlled randomized trial.

Memantine, an N-methyl-D-aspartate receptor antagonist, is approved in the United States and Europe for the treatment of moderate to severe Alzheimer disease (AD) and has also been investigated in patients with mild to moderate AD. To characterize the specific cognitive benefits of memantine in patients with mild to moderate AD, a post hoc analysis was conducted of a 24-week randomized, double-blind, placebo-controlled, clinical trial comparing memantine (10 mg twice daily) to placebo. Cognition was assessed using the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog) total score, individual items, and aggregated subscales, using a mixed model repeated measures analysis. As assessed by the ADAS-cog total score, participants in the placebo group demonstrated significantly more cognitive decline from baseline than participants treated with memantine at all visits beginning at week 8. Subjects treated with placebo also declined significantly more than individuals in the memantine group on 5 of 11 ADAS-cog individual items: orientation, language, comprehension, word finding, and recall of test instructions. Out of 3 ADAS-cog aggregated item subscales (language, memory, and praxis), outcomes in 2 (language and memory) favored memantine. Consistent with findings from trials conducted in moderate to severe AD patients, this post hoc analysis of a randomized clinical trial suggests that memantine benefits core aspects of language and some aspects of memory in patients with mild to moderate AD.

A 24-week randomized, controlled trial of memantine in patients with moderate-to-severe Alzheimer disease.

This study examined the efficacy and safety of memantine monotherapy in patients with moderate-to-severe Alzheimer disease (AD). Patients not receiving a cholinesterase inhibitor (N=350) were randomized to receive memantine (20 mg/d) or placebo during this 24-week, double-blind, placebo-controlled trial. Prospectively defined analyses failed to demonstrate a statistically significant benefit of memantine treatment compared with placebo on the Severe Impairment Battery (SIB) at week 24 end point, although a significant advantage was observed for memantine at weeks 12 and 18. The 19-item Alzheimer's Disease Cooperative Study-Activities of Daily Living Scale (ADCS-ADL19) did not differ significantly between groups in any analysis. Clinician's Interview-Based Impression of Change plus Caregiver Input (CIBIC-Plus) did not significantly favor memantine at week 24 despite a significant advantage for memantine at weeks 12 and 18. Other secondary outcomes showed no significant treatment differences. Post hoc analyses of potentially confounding covariates and alternative methods of imputing missing data did not substantially alter the results. Because of the violations of normality assumptions for the SIB and ADCS-ADL19, nonparametric analyses were performed; statistically significant benefit of memantine over placebo was demonstrated at week 24 for the SIB but not the ADCS-ADL19. The type and incidence of adverse events were similar in both groups.